List name of school, city and state, and grade completed (high school, college or vocational training)
Medical examinations, in accordance with the Americans With Disabilities Act, Van Buren County may require applicants to
undergo a medical examination, including drug testing, after an offer of employment has been made and prior to the
commencement of employment duties, and may condition the offer of employment entrance examination.
If you will be driving a county vehicle or regularly driving your own vehicle on county business, a driving-record check will be
required prior to employment.
I represent that the answers and information given by me in this application are true and complete without qualifications. I hereby
authorize Van Buren County to verify the same and to make any investigation of my background deemed necessary. I authorize
former employers, law enforcement organizations, educational institutions and any other third party to give Van Buren County
information they have regarding me without receiving written notice from them.
I understand that Van Buren County has the right to refuse to hire or immediately terminate my employment at any time if it
discovers that I have provided incomplete, untrue or misleading answers in this application or any other documents or forms at
any time during my employment.
I authorize Van Buren County to use any information in its possession concerning me for any purpose it deems appropriate
including disclosure of information to any third party without any notification to me of such disclosure and I release Van Buren
County from any liability in connection with such use of disclosure.
I request and authorize the release of all information regarding my employment to Van Buren County, including but
not limited to my performance in such employment, attendance, dates of employment and reason for leaving such
I hereby release you and all individuals or persons connected herewith from all liability for providing this information
and waive my right to written notice of the release to Van Buren County of any relevant information that may be
contained in my personnel file.
The following information is valuable for complying with various governmental reporting requirements. This
information will not be used as part of the selection process and will not be provided to the hiring department.
* indicates a required field